Echocardiographic
Abnormalities
RICHARD M. SCHIEKEN, MD, FACC
RICHARD E. KERBER, MD, FACC Iowa City, Iowa
in Acute Rheumatic
Fever
The echocardiographic velocity of circumferential fiber shortening and left atriai dimension were measured serially in two groups of children with acute rheumatic fever: Group I, six patients with valve regurgitation without congestive heart failure, and Group ii, seven patients with regurgitation and congestive heart failure. in Group I, the initial velocity of circumferential fiber shortening was increased to 1.90 f 0.31 circumferences per second (circ/sec) (mean f standard deviation). in Group ii, it was decreased (1.18 f 0.25 circkec). in Group I velocity of circumferential fiber shortening subsequently decreased but remained above the normal level; in Group ii it increased to exceed the expected normal value. Concurrent changes in left atriai dimension were observed in both groups. The initial left atriai dimension of Group I (2.2 f 0.75 cm/m2) was slightly increased and returned to normal (1.70 f 0.32) on follow-up study. The left atrial dimension of Group ii was greatly increased initially (2.70 f 0.81 cm/m2) and remained large (2.50 f 0.87). Three patients in Group II experienced rebound during corticosteroid withdrawal. in each the velocity of circumferential fiber shortening decreased, suggesting impaired cardiac contractility. The echocardiogram thus facilitates serial assessment of the severity of carditis in acute rheumatic fever.
In the evaluation of acute rheumatic fever the severity of the carditis predicts the degree of residual chronic rheumatic disease. Responses of the erythrocyte sedimentation rate and other variables in the acute phase are used to determine both the presence and duration of rheumatic activity.l However, the elevation of the erythrocyte sedimentation rate is often as striking in patients with joint involvement as in those with severe carditis.2 In this study we evaluated the usefulness of the echocardiogram in assessing the severity of carditis throughout the course of illness in patients with acute rheumatic fever. Acute rheumatic fever is a pancarditis and the characteristic changes of pericarditis3 myocarditis4 and valvulitis5 may be demonstrated in the echocardiogram. This study reports the serial echocardiographic changes from the onset of disease through convalescence in two groups of patients with acute rheumatic fever, one with mild valve regurgitation and one with severe valve regurgitation and congestive heart failure. Materials
From the Departments of Pediatrics and internal Medicine, College of Medicine, University of Iowa, Iowa City, Iowa. Manuscript received October 31, 1975, accepted January 7, 1976. Address for reprints: Richard M. Schieken. MD, Division of Pediatric Cardiology, University of Iowa Hospitals, Iowa City, Iowa 52242.
458
October 1976
and Methods
The study group comprised 14 patients aged 8 to 17 years with acute rheumatic fever, representing all patients with this diagnosis at the University of Iowa Hospitals from July 1973 to June 1975. Periods of observation ranged from 5 to 19 months. Two patients had combined mitral and aortic regurgitation. In both patients the murmur of aortic regurgitation disappeared by the 5th hospital day. Four patients had pericardial effusion. One patient had chorea with no clinical manifestations of cardiac involvement. Echocardiograms were performed using a Smith-Kline Ekoline 20 ultrasoaoscope with a 2.2 or 5 megahertz unfocused transducer. The tracings were re-
The American Journal of CARDIOLOGY
Volume 38
ECHOCARDIOGRAM IN ACUTE RHEUMATIC FEVER-SCHIEKEN
corded on a Honeywell 1856 strip chart recorder. All echocardiographic dimensions were measured from three sequential beats and averaged. The end-systolic dimension (LVDs) was measured just below the level of the mitral valve at the peak of the anterior movement of the left ventricular posterior endocardium (Fig. 1). The end-diastolic dimension (LVDd) was measured at the Q wave of the electrocardiogram. The mean velocity of circumferential fiber shortening (VCF) in circumferences per second (circ/sec) was calculated using the following formulas: LVDd - LVDs VCF (circ/sec) = LVDd x LVET
AND KERBER
The left ventricular ejection time (LVET)7 was obtained from the aortic valve echocardiographic tracing. Left atria1 dimensions were measured by the method of Hirata et aLs These dimensions were corrected for body surface area. The 13 patients with cardiac involvement were classified into two groups: Group I, six patients with valve regurgitation
but no clinical manifestations of congestive heart failure, and Group II, seven patients with valve regurgitation and congestive heart failure (Table I). Three echocardiographic studies were performed: (a) immediately on admission; (b) on the day that a course of corticosteroid therapy terminated or, if no corticosteroids were administered, on the 12th day after admission; and (c) during convalescence (the last time the patient was seen in the outpatient clinic). In three patients who experienced corticosteroid withdrawal rebound, defined as an abnormal in%reasF in erythrocyte sedimentation rate, additional echocardiographic studies were performed: at the termination of steroid therapy, during rebound and on reinstitution of steroid therapy. Erythrocyte sedimentation rate was determined in all patients on the day echocardiographic measurements were performed.
Results The patient with chorea who had no manifestations of carditis had normal echocardiographic findings, and his data are not included in the results. Of four patients with pericardial effusion, two manifested the effusion only in the echocardiogram; the other two had cardiac enlargement demonstrated by chest roentgenogram as well as echocardiographic evidence of pericardial effusion.
Mean velocity of circumferential fiber shortening (Table I): The normal pediatric values for the FIGURE 1. Composite echocardiogram. Left panel, the transducer is directed at the chordae tendineae, below the level of the mitral valve. The left ventricular diastolic dimension (LVDd) is measured on the Q wave of the electrocardiogram. The systolic dimension (LVD,) is recorded at the moment of peak anterior movement of the left ventricular posterior wall endocardium. Right panel, the transducer is directed to record the aortic valve leaflets. The left ventricular ejection time (LVET) is measured from the rapid opening of the aortic valve leaflet to closure.
GROUP I
echocardiographic dimensions and mean velocity of circumferential fiber shortening have been established.g The mean velocity of circumferential fiber shortening on the day of admission (a) was greater in patients in Group I than in patients in Group II, whose value was lower than the normal value of 1.34 circ/se&’ (P
Abnormalities
RICHARD M. SCHIEKEN, MD, FACC
RICHARD E. KERBER, MD, FACC Iowa City, Iowa
in Acute Rheumatic
Fever
The echocardiographic velocity of circumferential fiber shortening and left atriai dimension were measured serially in two groups of children with acute rheumatic fever: Group I, six patients with valve regurgitation without congestive heart failure, and Group ii, seven patients with regurgitation and congestive heart failure. in Group I, the initial velocity of circumferential fiber shortening was increased to 1.90 f 0.31 circumferences per second (circ/sec) (mean f standard deviation). in Group ii, it was decreased (1.18 f 0.25 circkec). in Group I velocity of circumferential fiber shortening subsequently decreased but remained above the normal level; in Group ii it increased to exceed the expected normal value. Concurrent changes in left atriai dimension were observed in both groups. The initial left atriai dimension of Group I (2.2 f 0.75 cm/m2) was slightly increased and returned to normal (1.70 f 0.32) on follow-up study. The left atrial dimension of Group ii was greatly increased initially (2.70 f 0.81 cm/m2) and remained large (2.50 f 0.87). Three patients in Group II experienced rebound during corticosteroid withdrawal. in each the velocity of circumferential fiber shortening decreased, suggesting impaired cardiac contractility. The echocardiogram thus facilitates serial assessment of the severity of carditis in acute rheumatic fever.
In the evaluation of acute rheumatic fever the severity of the carditis predicts the degree of residual chronic rheumatic disease. Responses of the erythrocyte sedimentation rate and other variables in the acute phase are used to determine both the presence and duration of rheumatic activity.l However, the elevation of the erythrocyte sedimentation rate is often as striking in patients with joint involvement as in those with severe carditis.2 In this study we evaluated the usefulness of the echocardiogram in assessing the severity of carditis throughout the course of illness in patients with acute rheumatic fever. Acute rheumatic fever is a pancarditis and the characteristic changes of pericarditis3 myocarditis4 and valvulitis5 may be demonstrated in the echocardiogram. This study reports the serial echocardiographic changes from the onset of disease through convalescence in two groups of patients with acute rheumatic fever, one with mild valve regurgitation and one with severe valve regurgitation and congestive heart failure. Materials
From the Departments of Pediatrics and internal Medicine, College of Medicine, University of Iowa, Iowa City, Iowa. Manuscript received October 31, 1975, accepted January 7, 1976. Address for reprints: Richard M. Schieken. MD, Division of Pediatric Cardiology, University of Iowa Hospitals, Iowa City, Iowa 52242.
458
October 1976
and Methods
The study group comprised 14 patients aged 8 to 17 years with acute rheumatic fever, representing all patients with this diagnosis at the University of Iowa Hospitals from July 1973 to June 1975. Periods of observation ranged from 5 to 19 months. Two patients had combined mitral and aortic regurgitation. In both patients the murmur of aortic regurgitation disappeared by the 5th hospital day. Four patients had pericardial effusion. One patient had chorea with no clinical manifestations of cardiac involvement. Echocardiograms were performed using a Smith-Kline Ekoline 20 ultrasoaoscope with a 2.2 or 5 megahertz unfocused transducer. The tracings were re-
The American Journal of CARDIOLOGY
Volume 38
ECHOCARDIOGRAM IN ACUTE RHEUMATIC FEVER-SCHIEKEN
corded on a Honeywell 1856 strip chart recorder. All echocardiographic dimensions were measured from three sequential beats and averaged. The end-systolic dimension (LVDs) was measured just below the level of the mitral valve at the peak of the anterior movement of the left ventricular posterior endocardium (Fig. 1). The end-diastolic dimension (LVDd) was measured at the Q wave of the electrocardiogram. The mean velocity of circumferential fiber shortening (VCF) in circumferences per second (circ/sec) was calculated using the following formulas: LVDd - LVDs VCF (circ/sec) = LVDd x LVET
AND KERBER
The left ventricular ejection time (LVET)7 was obtained from the aortic valve echocardiographic tracing. Left atria1 dimensions were measured by the method of Hirata et aLs These dimensions were corrected for body surface area. The 13 patients with cardiac involvement were classified into two groups: Group I, six patients with valve regurgitation
but no clinical manifestations of congestive heart failure, and Group II, seven patients with valve regurgitation and congestive heart failure (Table I). Three echocardiographic studies were performed: (a) immediately on admission; (b) on the day that a course of corticosteroid therapy terminated or, if no corticosteroids were administered, on the 12th day after admission; and (c) during convalescence (the last time the patient was seen in the outpatient clinic). In three patients who experienced corticosteroid withdrawal rebound, defined as an abnormal in%reasF in erythrocyte sedimentation rate, additional echocardiographic studies were performed: at the termination of steroid therapy, during rebound and on reinstitution of steroid therapy. Erythrocyte sedimentation rate was determined in all patients on the day echocardiographic measurements were performed.
Results The patient with chorea who had no manifestations of carditis had normal echocardiographic findings, and his data are not included in the results. Of four patients with pericardial effusion, two manifested the effusion only in the echocardiogram; the other two had cardiac enlargement demonstrated by chest roentgenogram as well as echocardiographic evidence of pericardial effusion.
Mean velocity of circumferential fiber shortening (Table I): The normal pediatric values for the FIGURE 1. Composite echocardiogram. Left panel, the transducer is directed at the chordae tendineae, below the level of the mitral valve. The left ventricular diastolic dimension (LVDd) is measured on the Q wave of the electrocardiogram. The systolic dimension (LVD,) is recorded at the moment of peak anterior movement of the left ventricular posterior wall endocardium. Right panel, the transducer is directed to record the aortic valve leaflets. The left ventricular ejection time (LVET) is measured from the rapid opening of the aortic valve leaflet to closure.
GROUP I
echocardiographic dimensions and mean velocity of circumferential fiber shortening have been established.g The mean velocity of circumferential fiber shortening on the day of admission (a) was greater in patients in Group I than in patients in Group II, whose value was lower than the normal value of 1.34 circ/se&’ (P
